# Tics (Transient and Provisional Tic Disorder) - Category: chronic - Review status: reviewed (every claim checked against a document named on this page) - Sources: AAN Practice Guideline: The Treatment of Tics in People with Tourette Syndrome and Chronic Tic Disorders (Neurology 2019) - Verified date: 2026-08 ## Verified against - AAN Practice Guideline: The Treatment of Tics in People with Tourette Syndrome and Chronic Tic Disorders (Neurology 2019) - Tics (Transient and Provisional Tic Disorder) - disease-level clinical article (tic-disorder-clinical.txt) ## Treatment metadata - No drug therapy in primary care (Reassurance & CBIT Referral) ## Complete treatment card ```text TICS (TRANSIENT AND PROVISIONAL TIC DISORDER) Sources: AAN Practice Guideline: The Treatment of Tics in People with Tourette Syndrome and Chronic Tic Disorders (Neurology 2019) Review status: REVIEWED against AAN Practice Guideline: The Treatment of Tics in People with Tourette Syndrome and Chronic Tic Disorders (Neurology 2019), Tics (Transient and Provisional Tic Disorder) - disease-level clinical article (tic-disorder-clinical.txt) (2026-08) IS IT THIS? - reference only, to read alongside your own examination SYMPTOMS - what the patient reports (5) - Vocal tics can be sniffing, grunting, humming, clicking, or repeating words, with shouted obscenities (coprolalia) affecting fewer than 10% of patients [chest recession · tics] - Most patients describe a premonitory urge - a vague need to perform the movement followed by relief afterward - and about 20% feel a sensory component like itching or tingling [itching · tingling] - Suppressing tics makes the premonitory urge build to a distressing level, and releasing it afterward can cause a rebound flare sometimes called purging [tics] - Many affected children also report significant anxiety, sleep problems, and poor impulse control [anxiety] - Parents often notice frequent tics right after school even though teachers report none during the school day [tics] SIGNS - what you find (3) - More than half of affected children show echophenomena - repeating others' words (echolalia) or movements (echopraxia) [echolalia] - The neurologic exam is otherwise normal apart from the tics themselves [tics] - A change in cognition, tics that occur during sleep, or constant unrelenting movement should raise concern for another diagnosis [tics] TESTS (2) - Brain MRI or CT is usually normal; research scans have found subtly reduced caudate volume correlating with OCD symptoms, but this is not routinely available - EEG is not routinely needed but can help distinguish tics from absence seizures if consciousness appears altered IF NOT THIS - what else fits (5) - Absence seizures, unlike tics, involve altered consciousness or staring, last longer, and are not made worse by anxiety - Stereotypies differ by starting before age 3, involving one repeated movement rather than several, being easier to control voluntarily, and appearing mainly when the child is excited - Chorea produces jerky involuntary movements of the shoulders, hips, and face that are more continuous than tics - Paroxysmal dyskinesia attacks are triggered by a startle or sudden movement, last only seconds to minutes, and are often preceded by an odd limb sensation - OCD movements relieve anxiety tied to specific compulsive thoughts, while tics are preceded by a vaguer, more subconscious urge Source StatPearls "Tourette Syndrome and Other Tic Disorders" - disease-level clinical article Status traced to the source above 1. NO DRUG THERAPY IN PRIMARY CARE (REASSURANCE & CBIT REFERRAL)[1st line] Adult Explain that tics are common, involuntary, and not deliberate or attention-seeking; that most transient and provisional tics improve or resolve within weeks to months without any treatment; and that drawing attention to the tic (telling the child to stop) usually makes it worse, not better. Refer for habit-reversal therapy / Comprehensive Behavioural Intervention for Tics (CBIT) if tics are causing functional impairment (social, academic, or physical) or if the child and family are motivated to pursue active treatment even without impairment. Screen for coexisting ADHD and obsessive-compulsive symptoms, which are common alongside tics and often cause more day-to-day difficulty than the tics themselves. - Watchful waiting while there is no functional impairment; refer sooner if tics are impairing or the diagnosis is uncertain. The guideline sets no review interval - it requires periodic re-evaluation of medication, not of watching Peds The great majority of presentations are children roughly 4-10 years old; provisional tic disorder is specifically tics present for under 12 months. Tics lasting beyond 12 months, or any history of vocal plus multiple motor tics together, should be discussed with a paediatrician or paediatric neurologist to consider Tourette syndrome, though the initial primary-care approach is the same. Source AAN Practice Guideline: The Treatment of Tics in People with Tourette Syndrome and Chronic Tic Disorders (Neurology 2019) Why This guideline states that clinicians should inform patients and caregivers that watchful waiting is an acceptable approach in people who do not experience functional impairment from their tics - the situation for most transient and provisional tics - and that CBIT (built on habit-reversal training) should be offered as an initial treatment option relative to medication where it is available. Medication - alpha-agonists such as clonidine or guanfacine, or antipsychotics such as risperidone, aripiprazole, haloperidol, or pimozide - is reserved in this guideline for more troublesome, persistent, or Tourette-spectrum tics, needs baseline and ongoing cardiac and metabolic monitoring, and is a specialist-initiated decision. It is deliberately not listed as a treatment option in this entry for that reason - this entry covers the primary-care presentation, which is transient or provisional (under 12 months), not chronic or Tourette-spectrum tics. Caution Do not start an antipsychotic or an alpha-2 agonist for tics in primary care. Note this is our position, not the guideline's - the AAN says physicians should prescribe alpha-2 agonists, and may prescribe antipsychotics, where benefit outweighs risk, and restricts neither to specialists. The reason to hold back here is monitoring: these drugs need baseline and repeat cardiac and metabolic checks that a Cairo clinic cannot reliably arrange, and behavioural therapy comes first in the guideline anyway. Refer for urgent assessment if the movement does not fit the usual tic pattern - for example, strictly one-sided, painful, associated with loss of a previously acquired skill, weakness, or altered consciousness. A typical tic is briefly suppressible and often preceded by a premonitory urge; a presentation without those features needs a different work-up. Screen for comorbid ADHD and obsessive-compulsive symptoms - both are common alongside tics and often cause more functional impairment than the tics themselves, so a missed comorbidity can matter more than the tic itself. Avoid drawing repeated attention to the tic in front of the child (telling them to stop, pointing it out) - this typically increases tic frequency rather than reducing it. The guideline's own priority: offer CBIT as the initial treatment ahead of medication where it is available (rec 7b), and assess for comorbid ADHD (3a) and OCD (4a) in everyone with tics. RED FLAG - A change in cognition, tics occurring during sleep, or constant movement are red flags that raise concern for alternative neurological diagnoses. 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